Nursing Elites

1. A client in the emergency department reports difficulty breathing. The nurse assesses the client’s appearance as depicted below: What action by the nurse is most important?

• A. Assess blood pressure and pulse.
• B. Attach the client to a pulse oximeter.
• C. Have the client rate his or her pain.
• D. Facilitate urgent radiation therapy.

Correct answer: A

Rationale: The correct action by the nurse is to assess the client's blood pressure and pulse. Difficulty breathing can be a sign of various conditions, including cardiac issues. Assessing blood pressure and pulse helps in determining the client's hemodynamic status and identifying any cardiovascular compromise. Option B is less crucial as attaching the client to a pulse oximeter may provide oxygen saturation levels but does not directly assess cardiac output. Option C is not the priority in this situation as the client's difficulty breathing is a more urgent concern. Option D is incorrect as urgent radiation therapy is not indicated based on the client's presentation.

2. A client receiving chemotherapy is experiencing severe nausea and vomiting. Which intervention should the nurse implement first?

• A. Administer antiemetics 30 minutes before chemotherapy.
• B. Offer small, frequent meals that are bland and easy to digest.
• C. Encourage the client to rest after meals to reduce nausea.
• D. Instruct the client to use relaxation techniques.

Correct answer: A

Rationale: The correct answer is A: Administer antiemetics 30 minutes before chemotherapy. Administering antiemetics before chemotherapy is crucial to prevent nausea rather than treating it after it occurs. This proactive approach helps in minimizing the side effects. Choice B, offering small, frequent meals, can be beneficial but is not the first intervention for severe nausea and vomiting. Choice C, encouraging rest after meals, may help but is not the priority when the client is experiencing severe symptoms. Choice D, instructing the client to use relaxation techniques, is not the first-line intervention for severe nausea and vomiting in a client receiving chemotherapy.

3. A patient with myelofibrosis is being treated with ruxolitinib. What should the nurse monitor to assess the effectiveness of this treatment?

• A. Blood pressure
• B. White blood cell count
• C. Hemoglobin and hematocrit
• D. Spleen size

Correct answer: C

Rationale: Monitoring hemoglobin and hematocrit is essential to assess the effectiveness of ruxolitinib in treating myelofibrosis. Ruxolitinib works by inhibiting JAK1 and JAK2, which are involved in the signaling pathways that regulate blood cell production. Therefore, monitoring hemoglobin and hematocrit levels can provide valuable information on how well the drug is managing the disease. Blood pressure, white blood cell count, and spleen size are not direct indicators of the treatment's effectiveness in myelofibrosis.

4. While a patient is receiving IV doxorubicin hydrochloride for the treatment of cancer, the nurse observes swelling and pain at the IV site. The nurse should prioritize what action?

• A. Stopping the administration of the drug immediately
• B. Notifying the patient's physician
• C. Continuing the infusion but decreasing the rate
• D. Applying a warm compress to the infusion site

Correct answer: A

Rationale: The correct action for the nurse to take when observing swelling and pain at the IV site during the administration of doxorubicin hydrochloride is to stop the administration of the drug immediately. Doxorubicin hydrochloride can cause severe tissue damage, so discontinuing the infusion is crucial to prevent further harm to the patient. Notifying the physician is important, but it should not take precedence over stopping the drug. Continuing the infusion, even at a decreased rate, can exacerbate tissue damage. Applying a warm compress is not appropriate in this situation and may worsen the tissue injury caused by the drug.

5. As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed if the client makes which statement?

• A. I should avoid blowing my nose.
• B. I may need a platelet transfusion if my platelet count is too low.
• C. I should take aspirin for my headache as soon as I get home.
• D. I will count the number of pads and tampons I use when menstruating.

Correct answer: C

Rationale: The correct answer is C. Taking aspirin is not recommended during periods of bone marrow suppression as it can increase the risk of bleeding. Aspirin is a nonsteroidal anti-inflammatory drug (NSAID) that can impair platelet function, further exacerbating the risk of bleeding. Choices A, B, and D are all appropriate statements for a client at risk for bleeding and undergoing chemotherapy. Blowing the nose gently, being prepared for a platelet transfusion if needed, and monitoring menstrual bleeding are all important aspects of self-care during this period.

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